Identification:
- Patient Name: John Smith
- Age: 62
- Gender: Male
Mechanism of Injury/Illness:
- Incident Details: Patient was found collapsed at home by his wife. She reported he had been complaining of chest pain for the last hour.
- Injury/Illness: Suspected Myocardial Infarction
Signs and Symptoms:
- Observations: BP 80/60, HR 110, SpO2 92% on room air, patient is diaphoretic and complaining of severe chest pain radiating to his left arm.
Pertinent Negatives:
- No reported history of recent trauma.
Treatment:
- Interventions:
- Administered 160mg Aspirin PO.
- Administered 0.4mg GTN SL.
- Placed on 10L O2 via NRB mask.
- Established IV access.
- ECG obtained.
- Medications:
- Aspirin 160mg
- GTN 0.4mg
- Response to Treatment: Chest pain slightly improved after GTN administration. BP increased to 90/64.
Allergies:
- Known Allergies: NKDA
Medications:
- Current Medications: Lisinopril 10mg daily, Atorvastatin 20mg daily.
Background:
- Medical History: Hypertension, Hyperlipidemia.
- Social History: Smoker, drinks alcohol occasionally.
Other Information:
- Next of Kin: Wife, Jane Smith, contact number 07700 900000
- Handover Time: 14:35
Identification:
- Patient Name: [patient’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Age: [age in years] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Gender: [patient’s gender identity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mechanism of Injury/Illness:
- Incident Details: [description of how the illness or injury occurred, including relevant context] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Injury/Illness: [name or description of the condition or injury identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Signs and Symptoms:
- Observations: [vital signs and symptoms observed at the scene or during transport] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Pertinent Negatives:
- [Describe any relevant signs or symptoms that were specifically absent and are helpful in ruling out other conditions or complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. Write as bullet points.)
Treatment:
- Interventions: [treatments or procedures performed on-scene or en route] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Medications: [list of medications administered during prehospital care, including doses if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Response to Treatment: [patient’s physiological or subjective response to treatments or medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies:
- Known Allergies: [any documented allergies, especially to medications or substances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications:
- Current Medications: [list of regular medications patient is taking prior to this event] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Background:
- Medical History: [relevant past medical history including chronic or acute conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Social History: [relevant details about social factors such as living situation, substance use, support system, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other Information:
- Next of Kin: [details of next of kin including relationship, name or contact if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Handover Time: [exact or approximate time of handover to hospital staff] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
